A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?
Contact the client's caregiver to discuss the client's comment.
Review the medical record to see if the client has reported abuse in the past.
Report the suspected abuse to the nurse manager.
Restrict family members from visiting with the client.
The Correct Answer is B
A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.
B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.
C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.
D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Frequently checking the top of the ears for sores is correct. The nasal cannula tubing can cause pressure injuries behind the ears over time. The family should check for redness or sores and use protective padding or adjust the tubing as needed.
B. Turning the oxygen up to 10 when the client has trouble breathing is incorrect. Oxygen flow rates should be adjusted only as prescribed by the provider. Increasing the flow rate without guidance can lead to complications, such as oxygen toxicity in clients with chronic respiratory conditions.
C. Using petroleum jelly to keep the nares moist is incorrect. Petroleum-based products are flammable and should not be used with oxygen therapy. Instead, a water-based lubricant should be used to prevent nasal dryness.
D. Removing the nasal cannula when eating is incorrect. Clients using a nasal cannula can continue wearing it while eating, as it allows them to receive oxygen continuously. If needed, a healthcare provider can recommend adjustments to oxygen flow during meals.
Correct Answer is C
Explanation
A. WBC 13,000/mm3 is slightly elevated and might indicate an infection, but it is not critically high in the context of COPD. The nurse should still monitor the client for signs of infection but is unlikely to require immediate intervention.
B. Potassium 3.7 mEq/L is within the normal range (3.5–5.0 mEq/L) and does not require reporting.
C. Hgb 20 g/dL is elevated and should be reported. High hemoglobin levels can indicate dehydration, polycythemia, or other conditions related to chronic hypoxia, which is common in COPD. This value is above the normal range (12–18 g/dL for adults) and requires further evaluation.
D. Iron 150 mcg/dL is within the normal range (50–170 mcg/dL for adults) and does not require reporting.
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